Cable-Stayed Face Lift: An Innovative Short-Scar Lift for Better Correction of Nasolabial Folds in East Asians.

BACKGROUND: The improvement of nasolabial folds by either lateral superficial musculoaponeurotic system rhytidectomy or minimal access cranial suspension lift alone is commonly performed, but patient satisfaction is often limited in East Asians. An innovative technique, termed the cable-stayed face lift, which combines the strengths of lateral superficial musculoaponeurotic system rhytidectomy and minimal access cranial suspension lift, was developed for improved results. METHODS: Between 2016 and 2019, 20 cable-stayed face lifts were performed in a single hospital. Two plastic surgeons independently evaluated postsurgery outcomes using a five-point Likert scale, where 5 = excellent, 4 = good, 3 = fair, 2 = no change, and 1 = worse. Patient satisfaction was assessed by relevant items from the FACE-Q questionnaire. RESULTS: Twenty patients with a mean age of 51 years underwent face-lift surgery. The mean follow-up ± SD was 11.3 ± 9.8 months. The five-point Likert scale score evaluated by surgeons was 3.65 ± 1.08. Patient-perceived age visual analogue scale (7.8 ± 4.4) exhibited a difference between preoperative actual age and postoperative apparent age. Patients demonstrated high satisfaction with outcome (67.5 ± 16.2) and satisfaction with lower face and jawline (76.2 ± 14.9). No major complication, hematoma, or seroma was observed. CONCLUSION: The authors' approach-cable-stayed face lift-offers a good alternative to provide a more effective effacement of nasolabial folds, by lifting the nasolabial folds with parallel vector and lower face and neck with the vertical vector. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Nasolabial Fold: A Micro-Computed Tomography Study.

BACKGROUND: The nasolabial fold is known to be a challenging midface feature for aesthetic physicians. However, the steric conformation of the structures related to the nasolabial fold has remained undefined because the composition and topography of this region are highly intricate. Therefore, this study aimed to clarify the three-dimensional structures of the nasolabial fold using micro-computed tomography and verify their detailed composition by means of histologic observation. METHODS: Twenty-four specimens were collected from the area beside the alae nasi to the area above the oral angle of 12 cadavers (mean age, 80.3 years) bilaterally. Twelve specimens were evaluated by means of phosphotungstic acid contrast staining, and the rest were evaluated by means of histologic staining. All specimens were divided into three regions and analyzed comprehensively. RESULTS: The medial region of the nasolabial fold had dense irregular connective tissue intermingled with muscle fibers; the lateral region of the nasolabial fold had numerous fibrous septa with abundant adipose tissue. The levator labii alaeque nasi and the zygomaticus minor were attached to the medial part of the nasolabial fold, and the fascial septa were intermittently tethered to the dermis, lateral to the nasolabial fold. The extension of the adipose tissue within the fascial septa was limited by the lateral border of the muscle attachment. CONCLUSIONS: Dimensional and distributional alterations of the adipose tissues with senescence could render the nasolabial fold deeper by increasing the depth of the subcutaneous layer, lateral to the fold. Thus, to ameliorate the fold, the adipose tissue, lateral to the fold, or the muscle traction, medial to the fold, should be altered.

New Insights Into 3-Dimensional Anatomy of the Facial Mimetic Muscles Related to the Nasolabial Fold: An Iodine Staining Technique Based on Micro-Computed Tomography.

BACKGROUND: This study aimed to introduce a novel approach to study the facial mimetic muscles (FMMs) related to the nasolabial fold (NLF) and realize the visualization of complex 3-dimensional (3D) structures of the FMM. METHODS: Micro-computed tomography (micro-CT) and iodine staining technique were used to obtain the 2-dimensional radiographs of the FMM. Materialise Mimics software was then used to reconstruct the 3D model of the FMM. RESULTS: The zygomaticus major muscle was not directly connected to the orbicularis oris muscle (OOM). The terminal fibers of the zygomaticus major muscle were located in the levator anguli oris. The surface of the FMM was covered with some unknown muscle fibers in the NLF. The terminal fibers of the zygolabialis ended in the middle of the ipsilateral OOM rather than the edge of the OOM. At the same anatomical level, the FMM fibers were so closely connected to each other that they were not separated by adipose tissue. A detailed 3D sequence of the muscle fibers in the modiolus at the corner of the mouth was determined. The muscle fibers in the modiolus were organized rather than disorganized. The terminal fibers of the levator anguli oris were located at the terminal fibers of the musculus depressor anguli oris at the corner of mouth. CONCLUSIONS: Although the micro-CT had many disadvantages, the micro-CT combined with iodine staining technique enabled the 3D anatomical study of the FMM related to NLF. We imported the 2-dimensional images obtained by micro-CT scanning into Mimics software, successfully reconstructed the FMM related to the NLF, and finally obtained images of complex 3D structures of the FMM related to the NLF. The shapes, positions, and 3D spatial relationships between the FMM related to the NLF were clearly visualized. The novel insights into the 3D anatomy of the FMM related to NLF may help understand the formation of the NLF. Finally, the results of this study may help improve rejuvenation surgery of the NLF in the near future.

Clockwise and Counterclockwise Le Fort I Movements Influence Nasolabial Morphology Differently.

BACKGROUND: Le Fort I maxillary advancements affect nasal proportions. However, there are no data on the three-dimensional nasal changes that occur with differential lateral plane adjustment (clockwise and counterclockwise movements) during Le Fort I maxillary advancements. This study analyzes and compares nasolabial soft-tissue changes after Le Fort I clockwise and counterclockwise repositioning. METHODS: Single-piece Le Fort I advancements were included. A retrospective study of patients split into clockwise and counterclockwise groups was performed. Preoperative and postoperative three-dimensional photographs (VECTRA 3D) were analyzed. Nasolabial anthropometric measurements were recorded using Mirror software. Statistical analysis involved paired t test to compare preoperative and postoperative measurements. RESULTS: Twenty-four patients were evaluated (12 per group), with 22 distinct nasolabial relationships measured. Counterclockwise movement showed a statistically significant increase in alar width (3.6 mm; p < 0.001), alar base width (1.6 mm; p = 0.009), oral width (3.2 mm; p = 0.02), and lip projection (3.4 mm; p = 0.04). Clockwise movement showed no statistically significant changes, with the largest position changes noted in alar width (2.7 mm; p = 0.07) and alar base width (1.7 mm; p = 0.09). CONCLUSIONS: Clockwise and counterclockwise Le Fort I advancements have a different effect on postoperative nasolabial morphology. Counterclockwise movements exhibit significant changes, widening the alar base and width and the oral and philtral widths. The impact on the nostril morphology and columella was similar between the groups. The differential impact on nasolabial appearance is important to recognize for treatment planning and patient counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Age-Related Changes in the External Noses of the Anatolian Men.

OBJECTIVE: Knowledge of age-related nasal region measurements in Anatolian men; growth changes between adult and old age. BACKGROUND: The nose plays a critical role in determining the external appearance of an individual. Craniofacial anthropometry has been commonly used in forensic anthropology and medicine. METHODS: A total of 300 men (100 between 20-40 years; 100 between 40-60 years and 100 60-up years) were measured using a photographic technic from the Image J program. From the landmarks, 13 linear distances and 3 angles were calculated and averaged for age groups. RESULTS: The means of nasal bridge lengths of three age groups were 60.30, 63.43 and 64.63 mm, respectively. The average nasal tip protrusions of three groups were 24.31, 26.69 and 27.53 mm, respectively. Nasolabial angle, nasal bridge length and tip protrusion, anatomic and morphologic nose width and root width were statistically different between the three age groups (p < 0.05). CONCLUSION: Results collected in this study could serve as a data bank for nasal anthropometry during aging and development. The assessment of teratogenic-induced traumas, craniofacial alteration, facial reconstruction, aging of dead person and personal identification may be assisted by age data from Anatolian men from age data banks. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical Approach to the Thick Nasolabial Folds, Jowls and Heavy Neck-How to Approach and Suspend the Facial Ligaments.

Patients with thick skin typically present with a redundant, baggy, lax skin envelope together with prominent nasolabial folds, jowls, and a heavy neck. Durable and natural-appearing rejuvenation is not possible unless the deformities are addressed adequately and harmoniously in these patients. Traditional superficial musculoaponeurotic system techniques do not include surgical release of the zygomatic cutaneous ligaments and repositioning of descendent malar fat pad, and may lead to an unbalanced, unnatural appearance and the lateral sweep phenomenon. Additional attempts to improve unopposed nasolabial folds such as fat grafting to malar region are more likely to result with a "stuffed" look, far from a natural and rejuvenated appearance, and must therefore be avoided. The facelift techniques including true release of the anchoring ligaments of the midface and allowing adequate repositioning of saggy tissues are ideal for these patients to obtain harmonious, natural result. Despite the extensive dissections, maximal release, and maximal lateral pull, additional maneuvers, e.g., platysmaplasty, subplatysmal fat removal, or partial resection of submandibular glands may be required for satisfying result in patients with heavy neck. In this article, the authors outline the relevant anatomy of the facial retaining ligaments and their implications to surgical management of patients with heavy skin are discussed.

Ethnic Rhinoplasty in Female Patients: The Neoclassical Canons Revisited.

BACKGROUND: Despite the substantial amount of research devoted to objectively defining facial attractiveness, the canons have remained a paradigm of aesthetic facial analysis, yet their omnipresence in clinical assessments revealed their limitations outside of a subset of North American Caucasians, leading to criticism about their validity as a standard of facial beauty. In an effort to introduce more objective treatment planning into ethnic rhinoplasty, we compared neoclassical canons and other current standards pertaining to nasal proportions to anatomic proportions of attractive individuals from seven different ethnic backgrounds. METHODS: Beauty pageant winners (Miss Universe and Miss World nominees) between 2005 and 2015 were selected and assigned to one of seven regionally defined ethnic groups. Anteroposterior and lateral images were obtained through Google, Wikipedia, Miss Universe, and Miss World Web sites. Anthropometry of facial features was performed via Adobe Photoshop TM. Individual facial measurements were then standardized to proportions and compared to the neoclassical canons. RESULTS: Our data reflected an ethnic-dependent preference for the multiple fitness model. Wide-set eyes, larger mouth widths, and smaller noses were significantly relevant in Eastern Mediterranean and European ethnic groups. Exceptions lied within East African and Asian groups. CONCLUSION: As in the attractive face, the concept of the ideal nasal anatomy varies between different ethnicities. Using objective criteria and proportions of beauty to plan and execute rhinoplasty in different ethnicities can help the surgeon plan and deliver results that are in harmony with patients' individual background and facial anatomy. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Americleft Project: Comparison of Ratings Using Two-Dimensional Versus Three-Dimensional Images for Evaluation of Nasolabial Appearance in Patients With Unilateral Cleft Lip and Palate.

This study was conducted to determine if nasolabial appearance is rated with comparable results and reliability on 3-dimensional stereophotogrammetric facial images versus standard clinical photographs (2-dimensional). Twenty-seven consecutively treated patients with repaired complete unilateral cleft lip and palate were selected. Six trained and calibrated raters assessed cropped 2- and 3-dimensional facial images. Nasolabial profile, nasolabial frontal, and vermillion border esthetics were rated with the 5-point scale described by Asher-McDade using the modified Q-sort method. Cropped 3-dimensional images were available for viewing by each rater, allowing for complete rotational control for viewing the images from all aspects. Two- and three-dimensional ratings were done separately and repeated the next day.Interrater reliability scores were good for 2-dimensional (κ = 0.607-0.710) and fair to good for 3-dimensional imaging (κ = 0.374-0.769). Intrarater reliability was good to very good for 2-dimensional (κ = 0.749-0.836) and moderate to good for 3-dimensional imaging (κ = 0.554-0.855). Bland-Altman analysis showed satisfactory agreement of 2- and 3-dimensional scores for nasolabial profile and nasolabial frontal, but more systematic error occurred in the assessment of vermillion border.Although 3-dimensional images may be perceived as more representative of a direct clinical facial evaluation, their use for subjective rating of nasolabial aesthetics was not more reliable than 2-dimensional images in this study. Conventional 2-dimensional images provide acceptable reliability while being readily accessible for most cleft palate centers.

The Addition of Platelet-Rich Plasma to Facial Lipofilling: A Double-Blind, Placebo-Controlled, Randomized Trial.

BACKGROUND: Lipofilling is a treatment modality to restore tissue volume, but it may also rejuvenate the aging skin. Platelet-rich plasma has been reported to augment the efficacy of lipofilling, both on graft take and rejuvenation, by altering the adipose-derived stem cells. The authors hypothesized that addition of platelet-rich plasma would increase the rejuvenating effect and shorten recovery time. METHODS: The study conducted was a single-center, double-blind, placebo-controlled, randomized trial (2012 to 2015). In total, a well-defined cohort of 32 healthy female patients enrolled in the study, with 25 completing the follow-up. All patients underwent aesthetic facial lipofilling with either saline or platelet-rich plasma added. Outcome was determined by changes in skin elasticity, volumetric changes of the nasolabial fold, recovery time, and patient satisfaction during follow-up (1 year). RESULTS: Platelet-rich plasma did not improve the outcome of facial lipofilling when looking at skin elasticity improvement, graft volume maintenance in the nasolabial fold. Reversal of the correlation between age and elasticity, however, might suggest a small effect size, and thus might not be significant with our small study population. CONCLUSIONS: This randomized, double-blind, placebo-controlled study clearly has shown that platelet-rich plasma significantly reduces postoperative recovery time but does not improve patient outcome when looking at skin elasticity, improvement of the nasolabial fold, or patient satisfaction. The reversal of the correlation between age and elasticity might indicate some effect on skin but requires more power in future studies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery.

BACKGROUND: The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue. OBJECTIVES: This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures. METHODS: Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue. RESULTS: Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer. CONCLUSIONS: The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. LEVEL OF EVIDENCE 4.

Detailed Anatomy of the Nasolabial Muscle in Human Fetuses as Determined by Micro-CT Combined With Iodine Staining.

PURPOSE: This study aims to investigate the 3-dimensional (3D) anatomical structure of the orbicularis oris and nasalis, which are closely associated with the appearance of the upper lip and lower part of the nose. The relationship of the complicated 3D anatomical structure with the outline shape was also determined. METHODS: Microcomputed tomography combined with iodine staining was used to scan the nasolabial tissues of 3 aborted fetuses. The strictly aligned, corrected, full-capacity, 2-dimensional (2D) grayscale images obtained were then used to reconstruct 3D structures using a 3D reconstruction software. RESULTS: 2D grayscale slices and a 3D anatomical model of the orbicularis oris and nasalis of the specimens were obtained. The 2D images and the 3D model confirmed the orbicularis oris anatomical structure reported in previous studies and also provided new insights (such as the close association of the formation of the philtral dimple, lip peak, philtral ridge, and nasal sill with the orbicularis oris). In addition, the results show that the nasolabial muscle consists of muscle fibers from different sources and is divided into four distinct parts: pars marginalis, pars peripheralis, muscle fibers of the levator labii superioris, and nasalis muscle fibers. CONCLUSION: The 3D anatomical structures indicate that the orbicularis oris and nasalis are closely associated with the appearances of the upper lip and lower part of the nose. The results may aid plastic surgeons in performing cleft-lip correction surgery.

Anatomical considerations regarding the location and boundary of the depressor anguli oris muscle with reference to botulinum toxin injection.

BACKGROUND: Hyperactivity of the depressor anguli oris muscle can lead to a drooping of the mouth corner, which can give a sad, tired, or almost angry look in some patients. Botulinum toxin type A has recently been used to relax these hyperactive muscles. However, it is difficult to inject botulinum toxin type A into the depressor anguli oris muscle because its medial border overlaps with the depressor labii inferioris, and its lateral border is adjacent to the risorius, zygomaticus major, and platysma muscles. The aims of this study were to determine the topography of the facial muscles at the mouth corner and to provide critical information for determining the safest and most effective depressor anguli oris muscle botulinum toxin type A injection site. METHODS: Forty-two hemifaces from Korean and Thai adult cadavers were dissected. RESULTS: The location of the modiolus was 11.0±2.6 mm (mean±SD) lateral and 8.9±2.8 mm inferior to the cheilion. The angle formed by the sagittal line passing through the modiolus (LV) and the line connecting the modiolus and the intersection point of the lateral border of the depressor anguli oris muscle and the mandibular border (LP2) was 44.7±13.7 degrees. The angle formed by LV and the line connecting the modiolus and the most concave point of the medial border of the depressor anguli oris muscle (LP3) was 31.8±8.5 degrees. CONCLUSION: These results suggest that the fan-shaped area bounded by LP2, LP3, and the mandibular border is the safest and most effective depressor anguli oris muscle injection site.

Regression and classification methods for nasolabial folds: a possible paradigm for computer-aided diagnosis of skin diseases.

Classification of facial features, for example, nasolabial folds, still relies mainly on clinical assessment, resulting in significant costs because of high intra- and interrater variability. Further, diagnosing skin diseases, for example, malignant melanoma, also can present challenges. In an attempt to reduce cost of medical care in future, we determined the utility of methods in image processing and statistical analysis to automatically quantify, for example, the structure of nasolabial folds. To the best of our knowledge, this is the first report of the application of computer technology to grading of nasolabial folds. When classifying severity of wrinkles on a scale of 1-5, the computer achieved an accuracy of 87% compared to the dermatologist, taken as the gold standard. Further, the computer program's capacity to sort the order of wrinkles from least to most wrinkled was 98% as accurate as the clinician(s). We conclude that by using computer technology, nasolabial folds can be categorized almost as accurately as by using grading by dermatologists, suggesting that computer technology may be a useful tool to grade nasolabial folds because a computer is always consistent. We hypothesize that, after additional studies, this technology also may be a useful tool to aid in diagnosing skin diseases.

Histomorphologic approach for the modiolus with reference to reconstructive and aesthetic surgery.

The modiolus is strongly associated with facial expression, beauty, and aging, and so it is often viewed as the main facial landmark, both functionally and aesthetically. This study examined the modiolus and the surrounding structures histomorphologically with the aim of providing useful information for reconstructive and aesthetic surgery. Nineteen embalmed cadavers (38 hemifaces; 8 males and 11 females; mean age at death, 66.9 years) were examined in this study. For macroscopic observations, the modiolus and facial artery in the perioral region of 28 hemifaces were revealed by meticulous dissection. The modiolus and its surrounding structures were then prepared from 12 hemifaces for routine histology and stained with hematoxylin-eosin and Masson trichrome. A tendinous tissue nodule in the modiolus was found in 21.4% of cases (ie, 6 hemifaces). The facial artery passed approximately 1 mm lateral to the lateral border of the modiolus. In the central region of modiolus, which was an area of convergence of muscle fibers, the tendinous structure appeared as dense irregular collagenous connective tissue. Particularly in the middle layer between the skin and the oral mucosa, it appeared as a dense, compact, and prominent shape horizontally. The finding of the existence of a tendinous structure in the central region of the modiolus, which could act as an anchor for the converging facial muscles, is expected to provide critical information in the field of facial plastic surgery.

Aging changes of the periorbita, cheeks, and midface.

The periorbita, cheeks, and midface are an area of complex facial form and function. There is a particular pleasing visual harmony of these regions in the youthful face. With time, the robust glow and fullness of youth fades and diminishes. The skin is the first component to show the passage of time as it dulls, wrinkles, and blemishes. This is followed by a slow loosening and sagging of soft tissues as they descend from their once-fixed points of the skeletal foundation. The smooth transitions between regions are separated and hollows and ridges appear. These processes continue throughout life and eventually are accompanied by the visible consequences of bone resorption. The faces age, and as the countenance of the human spring turns through summer into autumn, function follows form, and symptoms accompany signs. A thorough understanding of both youthful and elder anatomy as well as the stigmata of aging is prerequisite to perform rejuvenating procedures. This article discusses these changes and how the older anatomy becomes the new norm.

Effect of setback Le Fort I osteotomy on midfacial soft-tissue changes as evaluated by cone-beam computed tomography superimposition for cases of skeletal Class III malocclusion.

This study employed the cone-beam computed tomography (CBCT) superimposition method to evaluate postoperative midfacial soft-tissue changes in cases of skeletal Class III malocclusion after double-jaw surgery with setback and vertical reduction Le Fort I osteotomy. A retrospective study was carried out on 15 patients who had undergone maxillary setback Le Fort I osteotomy and mandibular setback sagittal split ramus osteotomy with alar cinch suturing and V-Y soft-tissue closure. Three dimensional CBCT volume scans were recorded preoperatively (T0) and 6 months postoperatively (T1) to measure soft-tissue changes of the upper lip and midface. Post-surgery, soft-tissue landmarks in the cheek and paranasal areas had moved forward; the soft-tissue thickness at the A-point had markedly increased (P<0.05); there was no significant change in the subnasale, and the midline of the soft-tissue of the upper-lip area had moved backward. The extent of the mean soft-tissue change at the labrale superius was greater than that at the other soft-tissue landmarks of the upper lip. The results suggest that maxillary setback movement of the maxilla by alar cinch suturing has a beneficial effect on paranasal soft-tissue and lip contours for patients with protrusive lip and acute nasolabial angle.

Soft tissue cephalometric norms for orthognathic and cosmetic surgery.

PURPOSE: Proportionality of the lower and middle thirds of the face is a key determinant of successful orthognathic treatment. A flatter profile and marked variance of the soft tissue envelope in the Japanese population complicates the accurate assessment of these proportions. This study aimed to identify gender differences and establish norms for Japanese young adults using the method of soft tissue cephalometric analysis (STCA) by Arnett et al (Am J Orthod Dentofacial Orthop 116:239, 1999). MATERIALS AND METHODS: Lateral cephalograms of 49 young normal Japanese subjects (19 men, 30 women) were selected from the archival records and analyzed with STCA. The Student t test was used to compare mean values of the male and female groups. RESULTS: Significant differences were found between women and men. Men had a flatter occlusal plane and a more acute nasolabial angle than women. Men showed larger values for upper and lower lip thickness, menton soft tissue thickness, and vertical face length, especially in the lower third of the face. Women had a more projected midface than men. Compared with established STCA norms, the Japanese have more midfacial projection. CONCLUSIONS: Significant gender differences were found in the thickness, lower third length, and midface projection in Japanese young adults, which should be taken into account when interpreting measurements for orthognathic surgical planning. These differences can serve as norms for STCA in young Japanese adults. Differences were noted between the reference values of Arnett et al and Japanese subjects.

Symmetry in nasolabial area of UCCL patients one year after primary lip repair with modified Millard technique.

OBJECTIVE: The aim of this study was to assess the nasolabial symmetry of unilateral complete cleft lip patients repaired by West China modified Millard technique. STUDY DESIGN: Photographs of 31 unilateral complete cleft lip patients were taken before, immediately after, and 1 year after the surgery. Photogrammetric measurements were taken to evaluate nasolabial symmetry. RESULTS: Symmetry for the christa philtri point was attained immediately after the surgery and maintained in the 1-year follow-up. The cheilion point and the sub alare point, however, did not achieve symmetry until 1 year after surgery. The alar point, unfortunately, never achieved satisfactory symmetry in this study. The ratio of symmetry for none of the above-mentioned facial landmarks had linear correlations with the width of the fissure or other facial anthropometric measurements. CONCLUSIONS: Symmetry could be achieved in most of the nasolabial anthropometric landmarks after our modified Millard procedure.

The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides.

The ideal treatment of the nasolabial fold, the tear trough, the labiomandibular fold and the mentolabial sulcus is still discussed controversially. The detailed topographical anatomy of the fat compartments may clarify the anatomy of facial folds and may offer valuable information for choosing the adequate treatment modality. Nine non-fixed cadaver heads in the age range between 72 and 89 years (five female and four male) were investigated. Computed tomographic scans were performed after injection of a radiographic contrast medium directly into the fat compartments surrounding prominent facial folds. The data were analysed after multiplanar image reconstruction. The fat compartments surrounding the facial folds could be defined in each subject. Different arrangement patterns of the fat compartments around the facial rhytides were found. The nasolabial fold, the tear trough and the labiomandibular fold represent an anatomical border between adjacent fat compartments. By contrast, the glabellar fold and the labiomental sulcus have no direct relation to the boundaries of facial fat. Deep fat, underlying a facial rhytide, was identified underneath the nasolabial crease and the labiomental sulcus. In conclusion, an improvement by a compartment-specific volume augmentation of the nasolabial fold, the tear trough and the labiomandibular fold is limited by existing boundaries that extend into the skin. In the area of the nasolabial fold and the mentolabial sulcus, deep fat exists which can be used for augmentation and subsequent elevation of the folds. The treatment of the tear trough deformity appears anatomically the most challenging area since the superficial and deep fat compartments are separated by an osseo-cutaneous barrier, the orbicularis retaining ligament. In severe cases, a surgical treatment should be considered. By contrast, the glabellar fold shows the most simple anatomical architecture. The fold lies above one subcutaneous fat compartment that can be used for augmentation.

Nuances with the mestizo tip.

Mestizo nasal tips are a challenge. A gradual approach is presented, emphasizing minimal tissue resection, reinforcement of support structures of the nasal tip, and use of sutures and grafts in a judicious manner. The final result should be tips with improved definition, rotation, and projection.